Exploring adherence to an early rule-out pathway for myocardial infarction in the emergency department using mixed-methods

Abstract Background Incorporating a high-sensitivity cardiac troponin assay into care pathway for the assessment of suspected acute coronary syndrome has enabled myocardial infarction to be ruled out earlier. Purpose Using mixed methods, we explored adherence an early rule-out in HiSTORIC (High-Sensitivity Cardiac Troponin on Presentation Rule Out Myocardial Infarction) randomised controlled trial. Methods In 16,972 consecutive patients evaluated clinician syndrome. Adherence was defined with presentation I concentrations <5ng/L and symptom onset >2 hours from without serial testing (type 1 adherence); ≤2 2 or between 5ng/L sex-specific 99th centile 3 adherence). Semi-structured interviews were conducted 23 clinicians aid interpretation quantitative analysis. Qualitative data coded organized themes. Results presenting >2hr onset, achieved 81% patients. ≤2hr 35% had second test. initial concentration centile, 65% Compared managed by who adherent pathway, over-testing non-adherence) more likely older (mean age 52±16 years versus 58±14, P<0.001) have history disease (11% 27%, P<0.001). contrast, under tended younger 49±16 63±15, P<0.001), female (50% 37%, lower levels (median 1.0ng/L IQR 1.0 2.0, 5.0ng/L 2.0–10.0) compared those whom performed according recommendations. interview revealed how influenced five main themes: guideline characteristics, patient healthcare practitioner, system scientific evidence. Clear visual layout fundamental achieving optimal adherence. Strong clinical suspicion promoted repeat deviation felt justifiable senior clinicians. Conclusion This analysis successful implementation aiding trial data. Younger less receive recommended testing. Clinical judgement is one reasons discontinuation Funding Acknowledgement Type funding sources: Foundation. Main source(s): British Heart Foundation